Sunday, March 07, 2004

News from NIMH

High Value of Low-Cost Interventions

Background: often, news reports about  mental illness focus on high-tech reports (fMRI, psychopharmacology).  This sort of thing captures the public's interest, and serves a purpose by reminding us of the role of research technology in improving quality of life and functional capacity for persons afflicted by mental illness.  The human brain is the most complex organ in the body; indeed; it is the most complex entity that we know of in the universe.  So it is understandable that the most modern technology would be needed to make advances in the field. 

Despite the value of the more glamorous studies, it is important to remember that effective treatment methodologies do not have to be expensive.  The study cited here is a good example of this.  Major Depressive Disorder is a serious problem.  Studies indicate that MDD has a economic impact each year in the USA of more than $40 billion. (1 2 3) Most of this cost comes from lost productivity.  Modern treatment yields response rates of about 70% in routine clinical practice.  Although treatment response does not always restore a person's occupational function to premorbid levels, it can have a significant impact.  Consider the fact when a person becomes unable to work, there are two sources of economic impact.  First, the person is not working, so that productivity is lost.  Second, providing support to the person generates costs that would not exist if the person were well.  Thus, effective treatment of each individual patient can have a significant positive effect on the economy but simultaneously increasing productivity and  reducing entitlement costs.

Study Summary:

"Care Managers" Help Depressed Elderly Reduce Suicidal Thoughts

An intervention that includes staffing doctors' offices with depression care managers helps depressed elderly  patients reduce suicidal  thoughts, a study funded by NIH's National Institute of Mental Health (NIMH) has found. Martha Bruce, Ph.D., Cornell University, Charles Reynolds, III, M.D., University of Pittsburgh, and colleagues report on the outcome of the intervention in three major Eastern U.S. metropolitan areas in the March 3, 2004 Journal of the American Medical Association.

Older Americans comprise 13 percent of the population but account for 18 percent of all suicides. The major risk factor for suicide in late life is major depression.

"Since most older Americans who kill themselves have seen their doctor within a month of the event, effectively treating depression in primary care is a preventive intervention that can save lives," noted NIMH Director Thomas Insel, M.D.

Reynolds and colleagues set out to demonstrate that by educating physicians and improving treatment up to guideline standards, a social worker, nurse or masters-level psychologist can significantly improve clinical outcomes. The "depression care managers" were assigned to 10 randomly selected primary care practices in greater Philadelphia, Pittsburgh and New York City. Each practice was paired with a similar practice, which served as a control by providing its "usual care" in the study, called PROSPECT (Prevention of Suicide in Primary care Elderly: Collaborative Trial).

In initial screenings over two years, about 12 percent of the primary care patients tested positive for depression. From these, 598, mostly females and two-thirds with major depression, were recruited into the study.

The care managers applied structured treatment guidelines: First, they offered patients the serotonin selective reuptake inhibitor (SSRI) or another antidepressant if clinically warranted. If a patient didn't want medication treatment, the doctor could recommend Interpersonal Psychotherapy (IPT) from the care manager, who was supervised weekly by a psychiatrist investigator. Occasionally, patients received combination treatment. The care managers actively followed up the patients, monitoring their symptoms, drug side effects and treatment adherence.

Suicidal thinking resolved more quickly in patients who received the intervention. Also, intervention patients had a more favorable course of depression, as measured by severity of symptoms, rate of treatment response and remissions. For example, at eight months, about 70 percent of intervention patients initially plagued by suicidal thoughts were free of them, compared to about 44 percent of "usual care" patients. Although the intervention didn't lift depression symptoms in patients with minor depression any more than usual care, it did significantly decrease suicidal thoughts in those who had them. Suicide itself occurs too infrequently in primary care for the study to have measured any impact on actual suicide rates, note the researchers.

"Without such structured, formal screening and diagnostic procedures, patients are less likely to volunteer information, accept a diagnosis of depression or initiate treatment," explained Reynolds. "Our finding in an elderly population adds to evidence from other studies that structured interventions can improve the quality of depression care in primary care."

The results of PROSPECT indicate that quality treatment of depression in primary care can be a prevention strategy to reduce the risk for suicide in late life.

Other researchers participating in the PROSPECT study are: Herbert Schulberg, Ph.D., Gail McAvay, Ph.D., George Alexopoulos, M.D., Cornell University; Thomas Have, Ph.D., Ira Katz, M.D., Ph.D., Gregory Brown, Ph.D., University of Pennsylvania; Benoit Mulsant, M.D., University of Pittsburgh; Jane Pearson, Ph.D., NIMH.

Analysis: This study described above shows that the use of a care manager can result in significant improvement in outcome, even though they were studying a population of persons who are elderly and who thus present more complex and difficult-to-treat problems.  It often is harder to demonstrate a treatment effect when the study population is inherently treatment resistant.  Thus, the demonstration that a low-tech, low-cost intervention can be helpful is impressive.  Considering that the population they studied is a population in which treatment is generally paid for by Medicare, and the fact that Medicare costs are a significant political issue, this finding is pertinent for those with an interest in cost containment in government.  When politicians embark on budget-cutting escapades, it is common for them to target programs when they do not understand the value of the program. Care management is one such target.  Recently, we have seen huge reductions in the staffing of care managers in public mental health clinics.  This is the kind of thing that can produce a temporary improvement in one program's balance sheet, but it is likely to generate greater costs elsewhere.   For additional information of the cost savings that can result from appropriate mental health care, see the NIMH publication at this web page.